Product Return Authorization Form

Hepworth Pura LLC d/b/a Highline Brands NY
1637 Route 9W Milton, NY 12547
OCM-AUCP-22-000021

Retailer Entity Name

d/b/a

OCM Lic #

Product Description

UID/Lot ID

Product Quantity

Customer Name

Customer Email

Date of Return

Reason For Return

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